Form MO780-0218 "Oil and Gas Well Conversion to a Water Well Application - Geological Survey Program" - Missouri

What Is Form MO780-0218?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MO780-0218 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-0218 "Oil and Gas Well Conversion to a Water Well Application - Geological Survey Program" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
GEOLOGICAL SURVEY PROGRAM
OIL AND GAS WELL CONVERSION TO A WATER WELL APPLICATION
WELL OWNER INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN MISSOURI
OPERATOR LICENSE NUMBER
Will the well remain under the current operator’s ownership?
Yes
No
Is the ownership of this well being transferred to a landowner?
Yes
No (If yes, please complete landowner section below)
LANDOWNER INFORMATION
LANDOWNER NAME
MAILING ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EMAIL ADDRESS
PRIMARY PHONE NUMBER WITH AREA CODE
WELL INFORMATION
API NUMBER
WELL NUMBER
PRODUCTION UNIT (LEASE OR SURFACE UNIT NAME)
COUNTY
DEPTH TO FRESH WATER
FRESH WATER PRODUCING STRATUM NAME
Injection
Production
Stratigraphic Test
WELL TYPE
FT.
Unknown
Other ____________________________________
PRE CONVERSION REQUIREMENTS
If this well is being transferred from an operator to a landowner, an oil and gas transfer of well(s) and/or transfer of injection permit(s) form
must be submitted with this conversion to a water well application.
Per 10 CSR 50-2.060(4) Conversion to Domestic Water Supply Well, the following is required for conversion of an oil and gas well to a domestic water
well:
An oil and gas well conversion to a water well application must be submitted within thirty (30) calendar days after proposed conversion of the
well.
The well must have been reconstructed, or for a stratigraphic test well, must have been constructed, as a water well by a Missouri permitted
water well installation contractor and must meet water well construction standards as set forth in the Water Well Drillers Act, Chapter 256,
RSMo and the implementing Missouri Well Construction Rules 10 CSR 23.
A well registration or certification, as appropriate per those rules, shall be received before the state geologist will approve the conversion
agreement and release the applicable bond.
WELL CONVERSION INFORMATION
NAME OF WATER WELL INSTALLATION CONTRACTOR
PERMIT NUMBER
PRIMARY PHONE NUMBER WITH AREA CODE
WELL CERTIFICATION/REGISTRATION NUMBER
DATE OF CONSTRUCTION/RECONSTRUCTION
CERTIFICATION
I, the undersigned, certify that:
I am authorized to act as an agent for the fore mentioned operator/landowner.
The facts stated herein are true, correct and complete to the best of my knowledge.
I understand this form shall be submitted no less than thirty (30) days after the conversion of the oil and gas well to a domestic water supply
well.
I have read, understand and am in compliance with the Missouri Code of State Regulations Oil and Gas Council Rules 10 CSR 50-2.060(4)
and Missouri Well Construction Rules 10 CSR 23.
I understand that upon approval of this conversion, future regulation of this well must be in compliance with Missouri Code of State
Regulations Missouri Well Construction Rules 10 CSR 23.
LANDOWNER SIGNATURE
DATE
FOR OFFICE USE ONLY
APPROVED BY
DATE
MO 780-0218 (04-18) SEND COMPLETED FORM TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY, GEOLOGIC RESOURCES SECTION,
PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
MISSOURI DEPARTMENT OF NATURAL RESOURCES
GEOLOGICAL SURVEY PROGRAM
OIL AND GAS WELL CONVERSION TO A WATER WELL APPLICATION
WELL OWNER INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN MISSOURI
OPERATOR LICENSE NUMBER
Will the well remain under the current operator’s ownership?
Yes
No
Is the ownership of this well being transferred to a landowner?
Yes
No (If yes, please complete landowner section below)
LANDOWNER INFORMATION
LANDOWNER NAME
MAILING ADDRESS
CITY
STATE
ZIP CODE
COUNTY
EMAIL ADDRESS
PRIMARY PHONE NUMBER WITH AREA CODE
WELL INFORMATION
API NUMBER
WELL NUMBER
PRODUCTION UNIT (LEASE OR SURFACE UNIT NAME)
COUNTY
DEPTH TO FRESH WATER
FRESH WATER PRODUCING STRATUM NAME
Injection
Production
Stratigraphic Test
WELL TYPE
FT.
Unknown
Other ____________________________________
PRE CONVERSION REQUIREMENTS
If this well is being transferred from an operator to a landowner, an oil and gas transfer of well(s) and/or transfer of injection permit(s) form
must be submitted with this conversion to a water well application.
Per 10 CSR 50-2.060(4) Conversion to Domestic Water Supply Well, the following is required for conversion of an oil and gas well to a domestic water
well:
An oil and gas well conversion to a water well application must be submitted within thirty (30) calendar days after proposed conversion of the
well.
The well must have been reconstructed, or for a stratigraphic test well, must have been constructed, as a water well by a Missouri permitted
water well installation contractor and must meet water well construction standards as set forth in the Water Well Drillers Act, Chapter 256,
RSMo and the implementing Missouri Well Construction Rules 10 CSR 23.
A well registration or certification, as appropriate per those rules, shall be received before the state geologist will approve the conversion
agreement and release the applicable bond.
WELL CONVERSION INFORMATION
NAME OF WATER WELL INSTALLATION CONTRACTOR
PERMIT NUMBER
PRIMARY PHONE NUMBER WITH AREA CODE
WELL CERTIFICATION/REGISTRATION NUMBER
DATE OF CONSTRUCTION/RECONSTRUCTION
CERTIFICATION
I, the undersigned, certify that:
I am authorized to act as an agent for the fore mentioned operator/landowner.
The facts stated herein are true, correct and complete to the best of my knowledge.
I understand this form shall be submitted no less than thirty (30) days after the conversion of the oil and gas well to a domestic water supply
well.
I have read, understand and am in compliance with the Missouri Code of State Regulations Oil and Gas Council Rules 10 CSR 50-2.060(4)
and Missouri Well Construction Rules 10 CSR 23.
I understand that upon approval of this conversion, future regulation of this well must be in compliance with Missouri Code of State
Regulations Missouri Well Construction Rules 10 CSR 23.
LANDOWNER SIGNATURE
DATE
FOR OFFICE USE ONLY
APPROVED BY
DATE
MO 780-0218 (04-18) SEND COMPLETED FORM TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES, MISSOURI GEOLOGICAL SURVEY, GEOLOGIC RESOURCES SECTION,
PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov